1. Pre-Operative Evaluation in the Geriatric Patient
Gabriel Daniels, MS4

2. Population Expanding
Adults >65 years are a growing population of surgical candidates:
~1/3 of US inpatient surgeries in , 3
Expected to double by , 6
~50% of Americans will have an operation after age 65 3
Greatest increases expected in vascular (~31%) and general surgery (~18%) 1

3. What does initial assessment entail? 1
American College of Surgeons and American Geriatrics Society recommend discussion of the following key categories during the pre- operative assessment immediately preceding surgery:
Goals of care
Fasting protocol
Antibiotic and anticoagulant prophylaxis
Medication reconciliation

4. Goals of Care
Assessment of patient’s wishes regarding treatment and aggression of management 1, 6
Discuss code status (i.e. DNR)
Assign healthcare proxy
50% of patients over the age of 60 have to make a medical decisions about their care in their final days of life 1
70% lacked decision making capacity, but 68% had advanced directives
Review surgical risks and updates to advanced directives accordingly

5. Fasting Protocol 1
Patients will be asked to fast prior to any procedure with anesthesia due mainly to aspiration risk
New data suggests short-term fasting may be possible:
Fasting from clear liquids > 2 hours before elective procedures
Water, non-pulp fruit juice, clear tea, black coffee
Fasting from foods may need to be upwards of 6-8 hours before elective procedures
Especially meats and fatty foods that slow the gastric emptying

6. Antibiotic and Anticoagulant Prophylaxis 1
Studies show that antibiotics given within 2 hours of first incision can provide a significant mortality benefit in the first 60 days post-op
Especially in procedures involving: abdomen, bowel, cancer, or extended time
Anticoagulation is provided for risks of blood clotting while immobile

7. Medication Reconciliation
Review all medications!
Prescription, Over-the-counter, Vitamins & supplements, Herbal agents
Consider stopping / holding non-essential medications 1
Use caution when assessing essential medications 1
Withdrawal period
Potential for disease progression
Anesthesia interactions
Perioperative risk reducers (i.e. beta-blockers, statins) 6

8. Limitations of Traditional Testing 3
Does not consider the physiology of the aging
Testing is often single-organ based
May not assess for possible Geriatric syndromes
Poor predictor of LOS, functional recovery, and institutionalization need post-operatively
Physiology: impaired left ventricular compliance, stiffening of the systemic vasculature, decreased lung mechanics, and reduced renal function
“Heart, lung, kidney, and vascular decline”

9. Indication to Test Geriatric Patients Further 1
The population of patients above the age of 65 should receive a thorough evaluation to ensure prevention of:
Post-operative complications
Functional decline
Loss of independence
Untimely morbidity and/or mortality

10. Geriatric Parameters Predicting Post-Operative Outcome
Frailty
Nutrition
Physical Function
Cognition
Mood

11. Frailty
Frailty is defined as increased vulnerability secondary to age-related decline in physiology and resiliance
Fried et al described frailty as 4:
Unintentional weight loss, Self-reported exhaustion, Weakness on grip strength, Slow walking, Poor physical activity
Others include: cognitive, mood, sensory social and past medical assessments
Edmonton Frailty Scale
Hopkins Frailty Score
Modified Frailty Index

12. Frailty Frailty is associated with 3: Increased LOS
Inability to discharge directly to home 6
Surgical complications / infections
Mortality

13. Nutrition 3
Increased age correlated with unhealthier nutrition secondary to:
Access
Appetite
Dental / Chronic disease
Medications
Metabolism
Psychological barriers
Many different scoring systems are available
Can also assess via Albumin and Prealbumin levels, though limitations exist

14. Nutrition Malnourishment is associated with 3: Higher mortality
Infections
Wound complications 6
Mechanical ventilation need or extended duration or need

15. Physical Function
Patients ability independently perform ADLs for fulfillment of their desired role, health, and well-being 5
Multiple ways to assess 3:
Subjective exercise tolerance (“Walk four blocks” / “Climb two flights”)
Maximal exercise test
Timed Up and Go Test (TUGT)
Need for assistance with ADLs
Function Questionnaires

16. Physical Function Poor functional status is associated with 3:
Unanticipated nursing home placement
Post-operative pneumonia
Post-operative site infection (i.e. MRSA)
Early post-operative mortality 6

17. Cognition
Important to assess baseline mental function prior to surgery
Multiple tests possible for assessment:
Mini Mental Status Exam (MMSE)
Telephone Interview for Cognitive Status
Montreal Cognitive Assessment (MOCA)
American College of Surgeons and American Geriatrics Society recommend use of the Mini-Cog Test and collateral interview 6

18. Cognition Cognitive impairment is associated with 3:
Post-operative delirium
Post-operative pulmonary complications
Poor spirometry and increased atelectasis
Longer duration of mechanical ventilation
Dementia 7
Post-operative delirium is associated with 3:
Post-operative functional decline 6
Dementia 7
Extended LOS, with increased cost and use of hospital resources 6
Discharge to long-term care / rehabilitation facilities
Death

19. Mood 3
High prevalence that should be screened for in pre-operative course
~7 million adults > 65 yo are affected by depression
Pre-operative depression rate higher than general population
Assessment
Hospital Anxiety Outcome Score
International Classification of Disease-9 criteria
Center for Epidemiological Studies – Depression measure
Mental Health Inventory

20. Mood 3 Depression is associated with: Post-operative delirium
Worse patient reported outcomes
Longer LOS
Increased likeliness for skilled nursing requirement (or other “non-home”)
Increased mortality rate

21. Summary
There is an expanding population of patients over the age of 65, with simultaneous increase in surgical candidates of that age group
Traditional pre-operative assessment is inadequate to properly screen the geriatric patient for surgical and post-operative risks
Assessment for frailty, malnourishment, poor functional status, cognitive impairment, and low mood can supplement understanding of surgical risk in geriatric patients
Present of such declines is associated with numerous post-operative complications, extended length of stay, discharge to non-home location, physiological decline, and even increased mortality

22. Works Cited
Mohanty, Sanjay et al. “OPTIMAL PERIOPERATIVE MANAGEMENT OF THE GERIATRIC SURGICAL PATIENT: Best Practices Guideline from ACS NSQIP/American Geriatrics Society.” programs/geriatric/acs nsqip geriatric 2016 guidelines.ashx.
Marwell, Julianna G., et al. “Preoperative Screening.” Clinics in Geriatric Medicine, vol. 34, no. 1, Feb , pp. 95–105.,
Kim, Sunghye, et al. “Preoperative Assessment of the Older Surgical Patient: Honing in on Geriatric Syndromes.” Clinical Interventions in Aging, vol. 10, 16 Dec. 2014, pp. 13–27.,
Fried, L P. et al. “Frailty in Older Adults: Evidence for a Phenotype.” The Journals of Geriatrics, vol. 56, no. 3, Mar. 2001, pp. M146–M156.,
Functional Status. American Thoracic Society: Quality of Life Resource, 2007,
Ward, William H. et al. “Optimal Preoperative Assessment of the Geriatric Patient.” Perioperative Care and Operating Room Management, vol. 9, 2 Nov. 2017, pp. 33–38., (17) /pdf.
Lingehall, Helena C. “Preoperative Cognitive Performance and Postoperative Delirium Are Independently Associated With Future Dementia in Older People Who Have Undergone Cardiac Surgery: A Longitudinal Cohort Study.” Critical Care Medicine, vol. 45, no. 8, Aug. 2017, pp. 1295–1303., spx.